CADTH HEALTH TECHNOLOGY EXPERT REVIEW PANEL

Nomination Form

Instructions

Background materials, including the Terms of Reference, are available on the CADTH website at

Completed nomination packages must be submitted to CADTH, addressed to the attention of Cheryl Holmes, Committee Services, either directly by the nominator or by the nominee no later than 4:00 p.m. EDT onThursday, April 7, 2016, via Email: Fax: (613) 226-5392.

Should you have questions,please submit by email

Note that applications must include the following:

Completed Nomination Form, signed and dated

Nominee’s curriculum vitae

Signed Conflict of Interest Disclosure Form(s)

Signed Code of Conduct Form.

Please provide the following information as part of the application to the Health Technology Expert Review Panel:

Nominator Information (not required for self-nomination)
Name
Salutation
First
Last
Contact Information
Address
Telephone
Email
Background
Occupation andemployer
Professional designation(s)
Area(s) of specialization (if applicable)
Relationship to nominee
Nominee Information
Name
Salutation
First
Last
Contact Information
Address
Telephone
Email
Background
Occupation andemployer
Professional designation(s)
Area(s) of specialization (if applicable)
Nomination Details
Nomination for / Core Member
Please note that the appointment term is two (2) years.

Provide a brief overview of the qualifications of the nominee (maximum 300 words).

Provide a brief rationale for this nomination (maximum 300 words).

References

This section applies to a self-nominating candidate. Please provide information for at least two references.

Reference #1
Name
Salutation
First
Last
Contact information
Address
Telephone
Email
Relationship to nominee
Reference #2
Name
Salutation
First
Last
Contact information
Address
Telephone
Email
Relationship to nominee

For Nominator, if applicable:

Signature of Nominator: ______Date:______

For Nominee:

I agree to allow my name to stand for nomination to CADTH’s Health Technology Expert Review Panel. I have reviewed the nomination package and understand the roles and responsibilities of the Panel’s members.

I acknowledge that if I am appointed to the Health Technology Expert Review Panel, this form and all other materials received by CADTH as part of the nomination will be kept on file. If I am not appointed to the Health Technology Expert Review Panel, all materials received by CADTH as part of my nomination will be destroyed.

Signature of Nominee: ______Date:______

CADTH HEATH TECHNOLOGY EXPERT REVIEW PANEL1

Nomination Form